1 R. TANDON. 2 ECG, accurate physical examination and radiology form the tripod on which rests the...

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R. TANDON

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ECG, accurate physical examination and radiology form the tripod on which rests the clinical diagnosis in Ped. Card. Omission of, unfamiliarity with or misinterpretation of any of these three tools spells disaster.

Alexander S. Nadas

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Investigations are complimentary to each other in helping reach an accurate clinical diagnosis.

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ECG is the quickest, safest, least expensive and most widely available cardiac investigative tool.

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Electrocardiogram : Utility Identify cardiac malposition. Atrial and ventricular hypertrophy

- specific dx.- assess severity

Pericard. and myocard. disease. Electrolyte imbalance. Atriovent. & intravent conduction

abn. Arrhythmias.

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In congenital heart disease interpretation of the ECG is useful only on the patient’s bedside.

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CONGENITAL HEART DISEASECONGENITAL HEART DISEASE

ECG Crucial data Age Cyanotic or acyanotic Heart size – x-ray

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Electrocardiogram

At Birth : RAD (+90 to +120) RVH

At 2 to 5 years :-Normal axis (+30 to +75)Normal LV dominanceTransitional period (Unstable ECG)

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CONGENITAL HEART DISEASE

CLASSIFICATION

L R shunts Obstr. lesions Cyanotic pts

• Atrial level Right sided With PS• Vent. Level Left sided With PAH• PA level

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CYANOTIC : Subgroups PS, no VSD, R to L at atrial level PS with VSD (TOF physiology). pulm flow (Transposition physiol.) PA pr , pulm. flow (Eisenmenger

physiol). Pulm. ven. obst. PA pr. normal, No PS, No PAH.

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L to R Shunts : Atrial levelQRS axis-30 to +150 Atrial septal

defect 2°QRS axis-15 to -120 Atrial septal defect

1°Atrial septal defect 2° - rsR1 – V1 - 95%RVH PAHAtrial septal defect 1° - right, left, right

+ left, V.H.

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L to R Shunts : Vent. & PA levelNormal axis.L.V. dominance or LVH.RVH PS or PAH.PDA : Left ventricular hypertrophy

with ST and T changes of ischaemia indicates associated Aortic stenosis or LVEFE.

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Obstructive lesions :-RVH : Right sided lesion (PS)

(Except in newborns and neonates).Left ventricular hypertrophy – left

sided lesion (Aortic stenosis, C of A0)ST and T changes in Coarct. of A0

indicates associated Aortic stenosis or LVEFE.

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Obstructive lesions :-As a rule severity of RVH or LVH is

consistent with the severity of obstruction.

Presence of ST and T changes.Severe obstr.Myocardial dis.

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Cyanotic : QP, No VSD, CE+ (R L at atrial level)

Pure PS - SevereEbsteins anomaly.

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Cyanotic : TOF physiology (VSD + PS)

Clinical : No CE, S1 normal.S2 single, eject syst.

murmur.X-ray : No cardiomegaly.

Ischaemic lungs. Ao large.

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RAD RVH RAD LVH LAD LVH LAD RVH

TOF RV TA AVC

DORV SV SV SV

TGASV

DORV (Small VSD)

DORV (Rare)

DORV(Rare)

Cyanotic : TOF physiology

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Cyanotic : TOF physiologyLAD or RADEquiphasic complexes across.precordium, q may be absent. Single ventricle.

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RAD RVH

RAD LVH

LAD LVH LAD RVH

TGA RV TA SV

TAPVC SV SV AVC

DORVPTA

- RVAVC

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SV - - -

Cyanotic : TGA physiologyCE + Congestive cardiac failure + Age - NB

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Cyanotic Patients : Eisenmenger Phys.

RAD RVH RAD LVH LAD LVH LAD RVH

VSD, PDA, APW

RV TA AVC

TGA Physiol.

SV SV SV

ASD 2° - - -

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Cyanotic Patients : Pulm. Ven. Obstru.

‘P’ Pulm, RAD, RVH.Hypoplastic left heartTAPVC with PV obstru.

(Xray – Diagnostic)

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Cyanotic : Miscellaneous(No PS, normal PA pr).RAD RVH - TA PVC.LAD RVH - Single atriumNormal ECG - SVC to LA.

Pulm. AV fistula.

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SPOT DIAGNOSIS BY ECG

ALCAPA Ebstein’s anomaly Ventricular inversion (l-loop) Situs inversus Hypertrophic cardiomyopathy

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Arrhythmias and conduction defects suggest specific congenital cardiac anomalies

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SSS ASD in Holt Oram synd. Sinus venosus ASD. AV canal defects Ebstein’s anomaly. Asplenia, polysplenia synd.

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Narrow QRS tachycardia

Ebstein’s disease. Cong. CTGA LV – RA shunt AV canal defects Older pts of TA and ASD 2°.

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Wide QRS tachycardia

ALCAPA Coron. arterio-ven. fistula Arrhythmogenic RV dysplasia.

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Atrioventricular conduction defects and pre-excitation syndrome Ebstein’s disease. Cong. CTGA

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Age : 3 yrs, acyanotic.

Dx. : PDA, No PAHShunt 2:1.

X-ray : No CE, Ao+, MPA +Vasc : N to +.

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Age : 2 m, cyanotic

Dx. : Transposition physiology

X-ray : CE ++, Vasc. ++.

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Age : 2 yrs, cyanotic

Dx. : Fallots’ physiology

X-ray : No CE, Vasc. , Ao+.

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Age : 12 yrs, cyanotic

Dx. : Eisenmenger physiology

X-ray: CE +, Vasc : Prominent hilar vasc.,

Ischaemic periphery.

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Electrocardiogram provides diagnostic help only on the bedside of the patient from whom the ECG has been taken.

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